Healthcare Provider Details

I. General information

NPI: 1003185273
Provider Name (Legal Business Name): PRISCILLA ELLIS-WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2011
Last Update Date: 12/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8626 LOWER SACRAMENTO RD SUITE #41
STOCKTON CA
95210-1835
US

IV. Provider business mailing address

1779 ERICKSON CIR
STOCKTON CA
95206-6314
US

V. Phone/Fax

Practice location:
  • Phone: 209-478-2487
  • Fax: 209-478-1476
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: